Download OpenSided MRI Patient Packet Date PATIENT`S SSN# PATIENT

OpenSided MRI Patient Packet
MMR#
PATIENT'S SSN#
Mr.
Mrs.
Ms.
Miss
Sex:
Date
PATIENT NAME
Last Name
Has your name changed since last visit?
Male
Yes
Age
Address
Middle Initial
Previous Last Name
No
Female DOB
First Name
Home Phone
Apartment#
City/State/Zip
Patient's Employer
Occupation
Address
Suite#
City/State/Zip
Work Phone
Emergency Contact
Phone#
To the best of my knowledge there (is)
(is not)
any indication that I may now be pregnant .
INITIALS
PATIENT REFERRED BY DR.
PERSON RESPONSIBLE FOR BILL, IF NOT PATIENT
Patient's relationship to person responsible for bill
Spouse
Child
Other
Name
Employer
Mailing Address
Mailing Address
City/State/Zip
City/State/Zip
Home Phone
Work Phone
Occupation
INSURANCE AND/OR INJURY INFORMATION
PRIMARY INSURANCE
Secondary Insurance
Group / Claim #
Subscriber Name
ID#
ID#
Employer#
IS THIS THE RESULT OF AN INJURY OR ACCIDENT?
Date of Accident
WORK RELATED
OTHER ACCIDENT/INJURY
AUTO ACCIDENT
If Auto: Claim/Policy#
Brief summary of accident
IF WORK RELATED INJURY: ( If this is a LABOR & INDUSTRIES claim please complete)
Date of Injury
Cause of Injury
Employer at Time of Injury
Claim#
We keep a record of the health care services we provide you. You may ask us to see and copy that record. You may also ask us to correct that record. We
will not disclose your record to others unless you direct us to do so or unless the law authorizes and compels us to do so. You may see your record or get
more information about it in this office.
Benefits are verified by your insurance carrier. This is not guarantee of payment, all charges are subject to insurance provisions. Finance charges are
applied to all unpaid balances.
ASSIGNMENT AND RELEASE: I hereby authorize that my insurance benefits be paid directly to physician or facility. I am financially responsible for any
balance due. I also authorize the Doctor or Insurance Company to release any information required to process this claim.
Signature
Date
The following items may become damaged or cause injury to others in a strong magnetic field.
THEY MUST NOT BE TAKEN INTO THE MRI SCAN ROOM.
Hearing aid
Jewelry (rings, earrings, etc.) Pager/cell phone
Belt buckle
Glasses
Wallet/money clip
Pocketknife
Bra/girdle/sanitary belt
Watch
Purse/pocket book
Credit or bank cards
Metal zippers/buttons
Safety pins
Pens/pencils
Artificial limb/prosthesis
Hairpins/barrettes Keys
Dentures/partial plates
Wigs/hair pieces
Coins
Retainers
Patient Symptoms
Were they caused by an accident or injury?
I attest that the answers I have provided to the questions on this form are correct to the best of my knowledge. I have read and
understand the entire contents of this form and have had the opportunity to ask questions regarding the information on this form.
Signature (Patient or Guardian)
Date
NOT ALL EXAMS INVOLVE INJECTIONS, ONLY COMPLETE BOTTOM PORTION IF YOU ARE RECEIVING CONTRAST.
Your physician has referred you to us for an MRI examination involving an injection of gadolinium based contrast. This contrast may be beneficial in
aiding the radiologist to interpret your images. We are prepared to treat any adverse reaction should it occur. Your physician is aware of the remote
possibility of a complication and feels that the diagnostic information obtained far outweighs the minimal risk of the procedure. The percentage of any
adverse reaction is < 5%.
INFORMED CONSENT FOR INTRAVENOUS CONTRAST INJECTION OF A GADOLINIUM BASED CONTRAST AGENT
For people with severely reduced kidney function, gadolinium contrast is considered a possible cause of a rare disease called nephrogenic systemic
fibrosis (NSF). It is suggested that patients who receive hemodialysis treatment for renal failure should schedule their hemodialysis for 2 to 4 hours after
gadolinium contrast injection. If you have renal failure but do not need dialysis, please tell the MRI technologist.
Weight lbs.
Have you ever had an allergic reaction to any type of contrast? If yes, please explain.
Yes
No
Are you allergic to any medications? If yes, please explain.
Yes
No
Have you ever had any (kidney) renal disease/failure or transplant? If yes, please explain.
Yes
No
Have you ever had any liver disease/failure or transplant? If yes, please explain.
Yes
No
Are you currently on dialysis?
Yes
No
Do you have diabetes?
Yes
No
Do you have a heart condition?
Yes
No
Do you have a history of asthma or emphysema?
Yes
No
Do you have a history of hypertension/high blood pressure?
Yes
No
I attest that the answers I have provided to the questions on this form are correct to the best of my knowledge. I have read and understand the entire
contents of this form and have had the opportunity to ask questions regarding the information on this form.
Signature (Patient or Guardian)
Supervising Technologist
Date
Name
DOB
ATTENTION: MRI PATIENTS AND ACCOMPANYING FAMILY MEMBERS
Patient safety is our primary concern. The MRI room contains a very strong magnet. Before you are allowed to enter, we must know if you
have any metal in your body. Some metal objects can interfere with your scan or even be dangerous, so please answer the following
questions carefully.
Have you ever had any of the following operations or surgical procedures? If yes, please explain.
Eye Surgery
Orthopedic surgery
Ear Surgery
Vascular surgery
Heart Surgery
Back surgery
Other:
Date(s):
Yes
No
Have you ever had any type of cancer? If so, please explain.
Yes
No
Have you ever been a machinist, welder, or metal-worker?
Yes
No
Have you ever been hit in the face or eye with a piece of metal?
(Including metal shavings, slivers, bullets, or BB's?)
Yes
No
Have you ever had a piece of metal removed from your eye?
Yes
No
Are you pregnant, possibly pregnant, or breast feeding?
Date of last menstrual period
DO YOU HAVE ANY OF THESE ITEMS IN YOUR BODY?
Yes
No
Pacemaker, Wires, or defibrillator
Yes
No
Brain aneurysm clips
Yes
No
Ear Implant
Yes
No
Eye Implant
Yes
No
Electrical stimulator for nerves or bone
Yes
No
Infusion pump
Yes
No
Stents, coil filter, or wires in blood vessels
Yes
No
Implanted catheter or tube
Yes
No
Artificial heart valve
Yes
No
Shunt
Yes
No
Surgical clips, staples, wires, mesh, or sutures
Yes
No
Orthopedic hardware(plates, screws, pins, rods, wires)?
Yes
No
Artificial limb or joint
Yes
No
Penile prothesis
Yes
No
Magnetic implants anywhere
Yes
No
Diaphragm or intrauterine device
Yes
No
False teeth, retainers, or magnetic braces
Yes
No
Permanent makeup(eye, brows,lips) body piercing and tattoos?
Yes
No
Bullets, BB's or pellets
Yes
No
Metal shrapnel or fragments
Patient HIPAA consent form
Consent for the use and disclosure of health information for treatment, payment or healthcare purposes.
I have obtained, read and understand the Notice of Privacy Practices for OpenSided MRI, which provides a complete description of
information uses and disclosures.
I understand that:
✔ As a part of my healthcare, OpenSided MRI originates and stores paper and/or electronic records pertaining to my health care
and health history, including symptoms, examination and test results, diagnoses and treatment.
✔ OpenSided MRI is not required to agree to the requested restrictions to the disclosure of your protected health information.
✔ I may revoke this consent, in writing, at any time with the exception of actions already taken. By refusal to sign or revoking of this
consent form may result in dismissal of care or treatment as permitted by Section 164.506 in the Code of Federal Regulations.
✔ OpenSided MRI reserves the right to change their Notice of Privacy Practices, at any time as permitted by Section 164.520 in the
Code of Federal Regulations. Should OpenSided MRI change their Notice of Privacy Practices, they will send a copy of the revised
notice to the address I've provided.
✔ It may be necessary for the organization to disclose my protected health information to another entity for treatment, healthcare
or billing and payment purposes and I allow OpenSided MRI to disclose this information to those entities.
I fully understand and accept the terms of this Patient HIPAA consent form. I acknowledge that I have received the Notice of Privacy
Practices from OpenSided MRI and have had any and all questions regarding these forms answered by the undersigned employee.
Patient Signature
Date
OFFICE USE ONLY
Patient consent received by
Consent added to patient's medical record on
Patient refused to sign consent
OpenSided MRI, LLC. employee signature
on